Provider Demographics
NPI:1346399813
Name:MAH, KENNETH L (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:L
Last Name:MAH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 W PAUL AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-9189
Mailing Address - Country:US
Mailing Address - Phone:559-432-4508
Mailing Address - Fax:
Practice Address - Street 1:4409 E INYO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-2977
Practice Address - Country:US
Practice Address - Phone:559-453-3806
Practice Address - Fax:559-453-6025
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS148591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ35265ZMedicare UPIN